About the Author
INTRODUCTION
I was intrigued by a statement in David Healey’s recent book, which implied that the vested interests of industry had influenced the diagnosis and treatment of gastric reflux in a similar way to that in which normal human sadness had been transformed into a multibillion dollars’ a year business through the marketing of ‘depressive disorders’ and their treatment with the SSRI class of drugs. (Healey, 2012, pp. 53-54)
I have discussed the latter issue at some length previously (Reid, 2010; Reid, 2015), and in light of these efforts I began to gather together various papers from the mid 1980’s onwards in support of this idea. It soon became apparent that the gradual morphing of the functional disorder known as gastric reflux (GR) into the clinical entity of gastroesophageal reflux disease (GERD) corresponded in timing with the rediscovery of Helicobacter pylori by Marshall and Warren, and their research linking it with gastric and duodenal ulcers. (Marshall, Warren, 1984) With the acceptance of a bacterial cause for peptic ulcer disease, the primary treatment now became antibiotics, which displaced drugs such as Zantac (ranitidine) and Prilosec (omeprazole). The former drug is an histamine 2 (H2) blocker, the latter a proton pump inhibitor (PPI), and both classes of drugs work to reduce gastric acid production. As research had already demonstrated that there is a correlation between severe and persistent GR and oesophageal carcinoma, it was relatively easy to give disease status to GR, and by association link all cases of troublesome reflux, including relatively mild ones, with some degree of cancer risk.
Another interesting thing I found was that the early guidelines stipulated various tests to determine how frequently the contents of the stomach entered the esophagus and how much acid was involved. Endoscopy was often used in order to assess the degree of esophageal inflammation and whether or not there was dysplasia. (Kahrilasa, Shaheenb & Vaezic, 2008; Fisichella & Patti, 2008) In this way a cut-off point was established below which patients simply had troubling GR and above which they had GERD – an actual disease, which mandated serious treatment by means of acid reduction with histamine 2 blockers or, more commonly with PPI’s. However, the current clinical guidelines for GERD assert that doctors do not need to carry out any of the elaborate, time consuming and costly tests; that all people complaining of heartburn most likely have GERD; and that all should be given PPI’s as the treatment of choice. (Katz, Gerson, Vela, 2013; NICE, 2014, Patti, 2016)
While treatment with PPI’s does provide relief from the troublesome symptoms caused by the erosive and irritating effects of gastric acid, helping to stop the inflammation and prevent morbidity, it does not stop the mechanism that caused the reflux in the first place, and this continues unabated. Thus, PPI’s must be given long-term or the problem returns. However, as discussed in part one of this paper, there are serious health concerns with the long-term use of PPI’s, namely an increased risk for the following:
- Nutritional deficiencies (e.g. B12)
- Susceptibility to food poisoning
- Dysbiosis
- Pneumonia
- Bone loss
- Hip fractures
- Infection with Clostridium difficile
- Dementia
- Renal disease
- Heart disease
(Reid, 2016)
The most important issue that is left unanswered by this approach is that gastric acid is not the real culprit here. Gastric acid secretion is vital to digestion and hence to health. In fact, there is emerging evidence that the lower esophageal sphincter (LES), which is responsible for stopping the stomach contents from entering the esophagus, is directly controlled by gastric acid levels, the rise of which causes it to contract. (Stiennon, 1995; Wright, 2009; Wright & Lenard, 2001)
It has been estimated that 25 – 40% of healthy adult Americans experience symptomatic ‘GERD’, most commonly manifested clinically by pyrosis (heartburn), at least once a month. Furthermore, approximately 7 – 10% of the adult population in the United States experiences such symptoms on a daily basis. Since the condition is closely linked to Western lifestyle and dietary habits (one might even say ‘caused by’ such factors), we can expect to see similar prevalence throughout the Western world. (Richter, 1992; Herbella et al., 2007; Patti, 2016) It is likely, moreover, that the real figures are actually much higher, as many of these people do not seek medical help. (Harmon & Peura, 2010; Talley & Ford, 2015) Thus, gastric reflux is a very common problem in the community, one that is very poorly understood and even more poorly treated by conventional medicine. Importantly, the research agenda for the diagnosis and treatment of this condition has been hijacked by vested interests, and therefore it is highly unlikely that any paradigm shift, or significant development will occur in the near future.
Such a deplorable state of affairs has only one redeeming feature: the early detection of cancer in those patients at high risk. However, since the vast majority of people who experience reflux are not at significant short-term risk and since this condition may readily be corrected by lifestyle changes (principally the intelligent management of the diet) and herbal medicines, we will proceed directly to the TCM approach to diagnosis and treatment.
The Stomach and the middle Jiao
In TCM the internal organs and their functions are paired according to Yin-Yang: Liver-Gallbladder; Heart-Small Intestines; Spleen-Stomach; Lung-Large Intestine; Kidney-Bladder. Of these pairs, the Spleen and Stomach have the closest relationship and may be considered as a single unit, often referred to by their location within the body: the middle Jiao. The Chinese word jiao is understood in this context to signify a body cavity (although in other contexts it may mean ‘roasted’ or ‘burnt’). The upper Jiao contains the Heart and Lung, while the lower Jiao contains the Kidney, Bladder and Colon.
The Stomach works closely with the Spleen to digest and absorb nutrients. The Qi of the Stomach, which is the yang organ of this pair, has a descending (i.e. Yin type) movement, i.e. it sends the partially digested matter down to the Small Intestine for further processing. This is part of the general trend for ‘turbid Yin’ (i.e. waste) substances to be sent downward for excretion. The Qi of the Spleen, which is the Yin organ, has an upwards and outwards (i.e. Yang quality) direction of activity. This ensures that the ‘clear Yang’ products of digestion (i.e. vital nutrients) are distributed throughout the body from the middle Jiao.
Thus, according to the traditional theory, the middle Jiao is responsible for normal assimilation of nutrients as well as normal elimination of waste material. Both the Stomach and Spleen are involved in the various aspects or stages of these two processes. If digestion is strong, elimination will also be complete and effective; if digestion is disturbed, elimination will also be affected. Moreover, if the functions of only one member of this pair are disrupted in some way, there will be a reflex disruption of function in the other organ. If the Stomach Qi becomes injured due to dietary factors or pathogens, not only will this have an effect on appetite and digestion; it will also impair the processes that control the elimination of waste materials.
The major physiological functions of the Stomach are to receive and digest solid and liquid foods. This activity depends upon the Spleen’s ‘transformation’ (i.e. digestion) and ‘transportation’ (i.e. distribution of nutrients) functions[1]. If the Stomach Qi becomes disturbed, due to the effects of various pathogenic factors, it may counterflow upward, resulting in reflux, belching, hiccup, nausea or vomiting. When the Stomach Qi loses its normal direction of movement, the Spleen Qi will be affected in a similar way. This may cause the stools to become loose or sloppy, with poor absorption of nutrients. In addition, waste materials are no longer effectively processed and internally generated pathogens, such as Damp, Heat and Phlegm may develop.
TCM emphasizes the crucial role of the middle Jiao in health maintenance and recovery from illness. Often, the critical first step in the journey through which one takes full responsibility for one’s state of health is to restore the normal healthy functioning of the digestive system – as so eloquently described by the author, Upton Sinclair. (Sinclair, 1911) Clearly, if a treatment is given that only masks the symptoms of digestive disorder without correcting the underlying condition, patients are condemned to a poor state of health for the rest of their lives.
Gastric Reflux in TCM
In the 14th century, Zhu Dan-xi described gastric reflux, noting that in some cases, which are more severe, esophageal constriction was a likely consequence. Zhu was also the first to describe the formula Zuo Jin Wan, which has a strong anti-reflux and anti-emetic action. (Yang, 1993, pp.25-30, 206-208). Zuo Jin Wan is frequently used today as a base formula, to which other herbal ingredients are generally added, in the treatment of this disorder (Maclean & Lyttleton, 2002, pp. 110-133).
Aetiology
Gastric reflux (fan suan) is generally discussed as an appendix to the heading of Epigastric Pain (wei wan tong) in traditional Chinese Internal Medicine (nei ke). The causes are primarily inappropriate dietary habits and emotional strain. The former affects the Stomach and Spleen; while the latter affects the Liver. Although either of these two factors alone may lead to GR, commonly both are involved to some extent.
Inappropriate diet includes: consumption of too many Heating foods (e.g. chilis, alcohol, coffee); specific foods to which an individual has a specific sensitivity (e.g. citrus fruits, radishes, garlic); irregular timing of meals, including eating too soon before retiring at night, eating when feeling stressed or while walking or rushing around; eating excessive quantities of food; consuming too many Cold and cooling foods; inappropriate fasting or strict dieting.
As noted above, Western dietary habits appear to have a lot to do with the high incidence of gastric reflux throughout the post-industrial, globalized, free market economies. In particular, obese patients are more prone to developing this condition. (Patti, 2016). These facts tie in very neatly with the TCM perspective.
The effects of stress and emotional strain are also common causes, as these may affect the Liver leading to Liver constraint and Qi stagnation. Emotional suppression, (e.g. of socially unacceptable emotions such as anger), prolonged frustration, disappointments, unfulfilled desires (often provoked by consumer advertising), amongst other things, disrupt the Liver’s function of ensuring the smooth and even flow of the Qi throughout the body.
The Spleen organ system may itself be injured by inordinate worrying, obsessive thinking and prolonged concentration, predisposing to invasion of the Spleen by the Liver Qi. Moreover, Spleen Qi deficiency may manifest in the failure of the Spleen Qi to ascend. This leads to failure of the Stomach Qi to descend with subsequent counterflow ascent of the Stomach Qi. (Maclean & Lyttleton, 2002, pp.104-106; Flaws & Sionneau, 2001, p.455; Shi, 2003, p.70).
Another very important factor in our particular cultural setting is the lack of exercise associated with our sedentary lifestyle. This has a profound influence on both the Liver Qi as well as the Spleen. If we compare the activity levels of people in pre-industrialized and primitive societies with those of our contemporaries, we can infer that normal activity levels for humans must be several orders of magnitude greater than those practiced by most of the present population. Even allowing for human adaptability, a healthy level of physical activity may only be achieved by very few people. In TCM terms, physical activity is necessary to support the Liver’s function of ensuring that the Qi flows smoothly and evenly; it is also necessary to maintain muscle tone and strength, which supports Spleen function. Thus, prolonged and persistent lack of exercise may lead to stagnation of the Qi and Liver constraint together with Spleen Qi deficiency. (Maclean & Lyttleton, 2002, pp. xx,xxi)
Pathogenesis
The various factors described above set in train a series of pathological changes that ultimately result in disordered movement of the Stomach Qi. As described previously, the normal directional movement of the Stomach Qi is downwards, propelling the contents of the stomach into the duodenum and small intestines and from there to large intestine. As a result of the above pathological changes, instead of sending the stomach contents downwards, the Stomach Qi now sends the stomach contents upwards and this is referred to as counterflow (qi ni) of the Stomach Qi, also referred to as ‘rebellious Qi’.
Excess and Deficiency Patterns
According to the paradigm of Yin-Yang, the same effect may be produced by causes, which are opposite in nature. In TCM these causes are broadly classified into excess and deficiency types. In the former, there are pathogenic factors present that need to be eliminated; while in the latter, various aspects of functional activity are lacking.
Pathogenic factors (a.k.a. ‘pathogens’) may have various effects, e.g. sensations of heat, sensations of cold, sensations of heaviness, pain or swelling. However, the one constant is that pathogens create stagnation. This is envisaged as an obstructive influence on the free movement of the Qi, Blood and body fluids. In the digestive tract stagnation of the Qi and stagnation of the fluid metabolism pathways and stagnation of the movement of the GIT contents are the critical factors, as will be seen in the next section, below.
In contrast to the effects of pathogens, which create stagnation by obstruction, deficiency patterns lead to stagnation due to a lack of motive force to move the contents of the stomach and intestines. Additionally, in a deficiency condition the pathways of fluid metabolism may also become congested. These processes lead to the pathological accumulation of partially digested food material as well as partially metabolized fluids, generating pathogens in a vicious cycle that worsens the stagnation and places an even greater burden on an already weak system.
One of the main effects of stagnation, particularly in the Stomach-Spleen system is that it disrupts the normal movements of the Qi in the middle Jiao, causing a reversal of direction leading to Qi counterflow.
Clinical Syndrome-Patterns
Clinically, there are seven commonly seen syndrome patterns underlying this phenomenon, all deriving in various ways from the two primary factors mentioned in the previous section:
1) Food stagnation.
When the quantity of food eaten exceeds the capacity of the Stomach and Spleen to process it, a residue of partially digested material remains in the Stomach. This is referred to as ‘food stagnation’. This means that the residual undigested food mass has become pathogenic and causes the Qi of both Stomach and Spleen to become stagnant. The major consequence of stagnation in the Stomach is that the Stomach Qi loses its normal direction of movement and tends to either fail to move at all or it begins to move in the opposite direction, resulting in counterflow upward movement, which underlies the mechanism of GR. In younger and middle-aged patients, this is a very common cause for GR.
2) Retained Damp (either Cold-Damp and Damp-Heat).
In chronic GR these pathogens are internally generated, generally as a result of inappropriate food choices, which over time weaken the Spleen. The Spleen’s ability to process fluids becomes impaired and pathological fluid accumulates and stagnates. This scenario leads to the development of Damp, which may be accompanied by either Cold or Heat. The stagnating effect of these pathogens causes the Stomach Qi to counterflow upwards. Some key clinical features are bloating (especially after eating), increased respiratory secretions, sensation of bodily heaviness, mental dullness (with an increased desire for caffeinated beverages), a thick tongue coat, loose stools or diarrhea.
3) Phlegm
We usually think of phlegm in terms of respiratory system pathology. However, TCM regards pathological changes in the digestive system as one of the principal sources of Phlegm (the pathogen). Phlegm may develop in the Stomach and Spleen in three main ways: Spleen deficiency, Damp-Heat and Liver constraint. Thus, Phlegm is usually seen clinically as a complication of these other conditions. In essence, disorders due to Phlegm may be regarded as a further development, or more severe form of disorders due to Damp (above). Generally, they are long term conditions and the underlying disorders that lead to the development of Phlegm are more pronounced. As this pathogen has a very strong tendency to cause stagnation, it obstructs the normal Qi movements of the middle Jiao (i.e. the Stomach and Spleen), leading to counterflow of the Stomach Qi and GR. Key clinical features include a sticky feeling in the mouth, sense of dryness in the mouth but no desire to drink, a greasy tongue coat and a slippery pulse.
4) Spleen-Stomach Qi (or Yang) deficiency.
The Spleen-Stomach may become deficient due to the effects of ageing, chronic illness, malnutrition (including prolonged or inappropriate fasting), constitutional weakness or a combination of these factors. In addition, the excessive consumption of Cold natured foods (such as raw foods, refrigerated items, iced drinks and fruit juices) may weaken the Yang Qi of the Spleen and Stomach, leading to a more severe state of deficiency that is characterized by signs of Cold (e.g. cold hands and feet, sensitivity to the cold), as well as fluid retention. This state of deficiency means that the functional potential of the digestive system has become considerably reduced, leading to reduction, or failure, of the various digestive functions. It manifests in poor appetite, feeling full after only eating a small amount of food, loose stools, muscular weakness, generalized wasting and also GR. The reason GR occurs is that one of the normal functions of the middle Jiao is to maintain the proper directional flow of the Qi. When this function starts to fail the Spleen Qi begins to go downwards (resulting in loose stools) and the Stomach Qi begins to counterflow upwards (resulting in GR).
5) Liver constraint, Qi stagnation.
As a result of stress and emotional strain, the Liver fails to adequately maintain the smooth and even flow of Qi throughout the body and the Qi begins to stagnate. In particular, the Qi of the Liver becomes obstructed and builds up tension such that the Liver Qi moves erratically, referred to as ‘Liver constraint, Qi stagnation’. This may manifest on an emotional level as emotional volatility with sudden outbursts. It may also manifest physically, with disordered function of the Stomach and Spleen. In health, the Liver provides support and direction for the normal movements of the Spleen Qi and the Stomach Qi. However, with Liver constraint, the Liver Qi now ‘invades’ the Spleen-Stomach and disrupts their functions. Thus, under the influence of a malfunctioning Liver, the Stomach Qi now moves upwards (giving rise to reflux) and the Spleen Qi may now move downwards (giving rise to loose stools or diarrhea). The characteristic feature of this pattern is that the GR is brought on or worsened by stress and emotional strain.
6) Stomach and Liver Heat.
Excessive consumption of Heating foods, such as chilis, alcoholic beverages (specifically spirits), coffee, chocolate and deep fried items, may eventually have the opposite effect on the Stomach to that produced by the excessive consumption of Cold natured food (as discussed in point 4, above), i.e. the Stomach may become over-heated. This is conceptualized in TCM as a type of pathogenic Qi (i.e. Heat), which produces characteristic signs and symptoms (dry mouth and lips, epigastric burning sensation, red tongue with a yellow coat). The Heat pathogen disrupts the normal directional flow within the middle Jiao, and the tendency of Heat to rise upwards causes the Stomach Qi to follow suit. This condition may be aggravated by long term Liver constraint, Qi stagnation (as discussed in point 5, above), which has a tendency to develop Heat, which may be transferred to the Stomach as the Liver Qi invades the Stomach.
7) Stomach and Liver Yin deficiency.
This condition may arise due to the effects of ageing, in the aftermath of a febrile illness or as a further development of the Stomach and Liver Heat (described above). The Yin and fluids become depleted within the Stomach and Liver, generating deficiency Heat within these organ systems. As Heat tends to rise upwards in the body, the Stomach Qi will counterflow upwards, and the disordered Liver Qi will also contribute to this process by ‘invading’ the Stomach.
(Maclean & Lyttleton, 2002, pp. 110-133; Flaws & Sionneau, 2001, pp. 455-458
Treatment
Treatment should be primarily directed to lifestyle changes – appropriate adjustments to the diet, daily exercise and stress management. While herbal and other natural medicines are highly effective in providing symptom relief and correcting the underlying imbalances, unless the causative factors are addressed, the condition is bound to recur. As mentioned in Part 1 (Functional Dyspepsia), recent studies have shown that simply by reducing food intake, the majority of patients will experience remission of GR. (Randhawa, Gillessen, 2013; Randhawa, Mahfouz, Selim, Yar, Gillessen, 2015)
The key point in dealing with GR is intelligent management of the diet. The patient must learn to only eat when truly hungry; the stomach must be permitted to empty before more food is taken in. This is a very simple principle, that is rarely fully understood nor followed, particularly in Western countries where food is abundant all year around. The other aspect to this concept of food stagnation is to avoid overfilling the stomach at each meal. Again, this is a very simple principle, that is generally overlooked or ignored.
Commonly used classical herbal formulas:
- Food stagnation: Bao He Wan
- Liver constraint, Qi stagnation (with or without stagnant Heat); Liver Qi invasion of the Stomach: Si Ni San, Chai Hu Shu Gan San, Dan Zhi Xiao Yao San (a.k.a. Jia Wei Xiao Yao San)
- Stomach and Liver Heat: Hua Gan Jian, Zuo Jin Wan
- Retained Phlegm-Damp: Ping Wei San, Er Chen Wan, Wen Dan Tang
- Spleen-Stomach Qi (or Yang) deficiency: Xiang Sha Lui Jun Zi Tang, Fu Zi Li Zhong Wan
- Stomach and Liver Yin deficiency: Yi Guan Jian
(Maclean & Lyttleton, 2002, pp. 110-133; Flaws & Sionneau, 2001, pp. 456-458; Shi, 2003, pp.70-71)
TREATMENT PROTOCOLS WITH PREPARED CHINESE HERBAL FORMULAS
Food stagnation
Dull epigastric pain or discomfort with a sensation of fullness and distention, malodorous belching, nausea or vomiting, discomfort is alleviated by belching or vomiting or passing flatus, alternating loose stools and constipation, thick and greasy tongue coat, slippery or wiry-slippery pulse.
P/T: Resolve food stagnation and promote digestion, redirect the Stomach Qi downwards.
Bao He Wan (Citrus & Crataegus Formula BP004) a.k.a. DIGEST-AID FORMULA (Bao He Xiao Shi Fang) CM102
Variations:
- Severe reflux
+ Ban Xia Hou Po Tang – Jia Wei (Pinellia & Magnolia Combination BP067)
Liver constraint, Qi stagnation
Sensation of distention in epigastrium and/or hypochondria, symptoms brought on by stress and emotional strain, sighing, normal or pale tongue with a thin white coat, wiry pulse.
P/T: Soothe the Liver to relieve constraint, regulate the Qi and harmonise the middle Jiao
REFLUX & DYSPEPSIA FORMULA (He Wei Li Qi Fang) CM137
Liver Fire invading the Stomach
Bitter taste in the mouth, dry throat, distending pain in the hypochondria, irritability, red tongue with a yellow coat, wiry-rapid pulse.
P/T: Clear Heat from the Liver and harmonize the Stomach
Zuo Jin Wan (Coptis & Evodia Formula) + Chai Hu Shu Gan Wan (Bupleurum & Cyperus Combination BP006) a.k.a. QI MOVER FORMULA (Chai Hu Shu Gan Wan) CM193
Spleen-Stomach Qi or Yang deficiency
Poor appetite, bloated sensation in the epigastrium, feels better with application of warmth and pressure, loose stools, pale tongue with a white and moist coat, wiry-thready pulse.
P/T: Warm-tonify the middle Jiao, strengthen the Spleen and harmonize the Stomach
Xiang Sha Liu Jun Zi Wan (Saussurea & Cardamon Formula BP028) a.k.a. DIGESTIVE TONIC FORMULA (Xiang Sha Liu Jun Zi Tang) CM155
Variation:
a) Food stagnation (reflux occurs after eating or worsened by eating, thick tongue coat)
+ Bao He Wan (Citrus & Crataegus Formula BP004) a.k.a. DIGEST-AID FORMULA (Bao He Xiao Shi Fang) CM102
b) Marked Yang deficiency (cold intolerance, cold extremities, deep-slow pulse)
Fu Zi Li Zhong Wan – Jia Wei (Dangshen & Ginger Formula M* BP070)
Turbid Damp or Phlegm-Damp retention
Fullness and distention in the epigastrium, sensation of bodily heaviness and fatigue that is better with exercise, loose stools, possibly excessive mucous production (nose or lungs), thick and greasy tongue coat, moderate or slippery pulse.
P/T: Dry damp and resolve Phlegm, promote Spleen function, move the Qi and harmonize the Stomach
Ping Wei San (Magnolia & Ginger Combination BP088) – more Damp
Or
Ban Xia Hou Po Tang – Jia Wei (Pinellia & Magnolia Combination BP067) – more Phlegm
Variations:
c) Severe condition
+ Wen Dan Tang (Bamboo & Hoelen Formula BP050) a.k.a. CLEAR THE PHLEGM FORMULA (Wen Dan Tang) CM180
Yin deficiency of the Spleen-Stomach
Post febrile illness, elderly patient or Yin deficiency constitution (body tends to overheat and there are signs of Dryness, such as constant thirst, dry skin, dry eyes, etc.), normal or dry stools, experiences gastric discomfort when eats or drinks quickly (i.e. feels more comfortable when eating slowly and drinking small sips of liquid), red tongue with scanty coat, thread pulse that may also be rapid.
P/T: Nourish the Yin and harmonise the middle Jiao.
Zhi Yin Gan Lu Yin (Rehmannia & Asparagus Formula BP052)
Variation:
a) With constipation:
+ Run Chang Wan (Linum & Rhubarb Formula BP019
b) With Spleen Qi deficiency (normal or loose stools):
+ Shen Ling Bai Zhu San (Ginseng & Atractylodes Formula BP020)
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[1] In the Western physiological paradigm, these activities involve the small intestines, lymph and circulatory systems.